Healthcare Alert

Hospital Outpatient E&M under OIG Focus

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The OIG determination that E&M coding, especially the determination of new patient vs. established patient criteria will become an increasingly important area for physician practices, especially inside institutions that are switching EMR and billing records. Many of these conversions have led to erroneous classification.

The OIG Work Plan for Part A states a review of Medicare outpatient payments made to hospitals for evaluation and management (E/M) will be conducted in 2015. The focus is specific to E/M services for clinic visits billed at the new-patient rate to determine whether those claims were appropriate and will recommend recovery of overpayments.

Preliminary OIG work identified overpayments occurred because hospitals used new-patient codes when billing for services to established patients. The rate at which Medicare pays for E/M services requires hospitals to identify patients as either new or established, depending on previous encounters with the hospital.

According to Federal regulations, the meaning of "new" and "established" pertains to whether the patient has been seen as a registered inpatient or outpatient of the hospital within the past 3 years. (73 Fed. Reg. 68679 (November 18, 2008).) (OAS; W-00-14-35627; expected issue date: FY 2015).

OIG and Quality of CareThe OIG 2015 planned work will examine settings in which OIG has identified gaps in program safeguards intended to ensure medical necessity, patient safety, and quality of care. The government continues to strive to pay for quality and access of health care services.

Marcum LLP's experience within the Healthcare industry covers the full continuum of care with a special focus within the post-acute care geriatric segments of the industry, hospitals and physician practices.

The Internal Revenue Service and Treasury Department will release new rules to address workarounds by high-tax states that are designed to help their residents manage new caps on federal tax deductions.

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